Application for Significant Public Benefit Entrepreneur

Application for Entrepreneur Parole
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-941
OMB No. 1615-0136
Expires 04/30/2022

What Is the Purpose of Form I-941?
Form I-941, Application for Entrepreneur Parole, is for entrepreneurs to: (1) make an initial request for parole based upon
significant public benefit, (2) a subsequent request for parole for an additional period, or (3) file an amended application
to notify USCIS of a material change.

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Parole allows you to be physically present in the United States for a limited time period and specific purpose based upon a
significant public benefit or urgent humanitarian rationale. A person who has been “paroled” into the country has not been
admitted to the United States and remains an “applicant for admission” even while paroled.
The Department of Homeland Security (DHS), as a matter of discretion, may grant advance parole and issue an Advance
Parole Document to enable you to appear at a U.S. port-of-entry to seek parole into the United States. A transportation
company (for example, a commercial airline) may accept the document in lieu of a visa as an authorization for the holder
to travel to the United States. An Advance Parole Document does not substitute for any required passport.
WARNING: A grant of advance parole or issuance of an Advance Parole Document does not entitle you to be paroled
into the United States. Upon your arrival at a U.S. port-of-entry, a U.S. Customs and Border Protection (CBP) officer will
make a separate discretionary decision whether to parole you into the United States.
WARNING: DHS may revoke or terminate parole or an Advance Parole Document at any time, including while you are
outside the United States. In that event, you may be unable to return to the United States unless you have a valid visa or
other document that permits you to travel to the United States and seek admission.

Who May File Form I-941?

An entrepreneur may file Form I-941 to request consideration for parole for the entrepreneur. Requests for parole for the
spouse and children of an entrepreneur must be filed with Form I-131, Application for Travel Document in accordance
with Form Instructions.
Only one entrepreneur may request parole per application. Additional entrepreneurs requesting parole through the same
start-up entity must file separate applications.
If you are not currently in the United States based on a grant of parole, you must file this application to make an initial,
advance request for entrepreneur parole either from within the United States or while outside the United States. Once
approved, you then may request parole at a U.S. port-of-entry (airport, seaport, or land border) from CBP after arriving
from outside the United States.

General Instructions
USCIS provides forms free of charge through the USCIS website. In order to view, print, or fill out our forms, you should
use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not
have Internet access, you may call the USCIS National Customer Service Center at 1-800-375-5283 and ask that we mail
a form to you. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Signature. Each application must be properly signed and filed. For all signatures on this application, USCIS will not
accept a stamped or typewritten name in place of a signature. If you are under 14 years of age, your parent or legal
guardian may sign the application on your behalf. A legal guardian may also sign for a mentally incompetent person.
Filing Fee. Each application must be accompanied by the appropriate filing fee. (See the What Is the Filing Fee section
of these Instructions.)
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Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the What Evidence
Must You Submit section of these Instructions.
Biometric Services Appointment. USCIS may require that you appear for an interview or provide fingerprints,
photograph, and/or signature at any time to verify your identity, obtain additional information, and conduct background
and security checks, including a check of criminal history records maintained by the Federal Bureau of Investigation
(FBI), before making a decision on your application. After USCIS receives your application and ensures it is complete,
we will inform you in writing if you need to attend a biometric services appointment. If an appointment is necessary, the
notice will provide you the location of your local or designated USCIS Application Support Center (ASC) and the date
and time of your appointment or, if you are currently overseas, instruct you to contact a U.S. Embassy, U.S. Consulate, or
USCIS office outside the United States to set up an appointment.

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If you are required to provide biometrics, at your appointment you must sign an oath reaffirming that:
1. You provided or authorized all information in the application;

2. You reviewed and understood all of the information contained in, and submitted with, your application; and
3. All of this information was complete, true, and correct at the time of filing.

If you fail to attend your biometric services appointment, USCIS may deny your application.

Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that you
must submit an original document. USCIS may request an original document at the time of filing or at any time during
processing of an application, petition, or request. If USCIS requests an original document from you, it will be returned to
you after USCIS determines it no longer needs your original.
NOTE: If you submit original documents when not required or requested by USCIS, your original documents may
remain a part of the record, USCIS will not automatically return them to you, and your original documents may be
immediately destroyed upon receipt.
Translations. If you submit a document with information in a foreign language, you must also submit a full English
translation. The translator must sign a certification that the English language translation is complete and accurate, and
that he or she is competent to translate from the foreign language into English. The certification must include the
translator's signature. DHS recommends the certification contain the translator's printed name and the date and the
translator's contact information.
How to Fill Out Form I-941

1. Type or print legibly in black ink.

2. If you need extra space to complete any item within this application, use the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or print your name and Alien Registration Number (A-Number)
(if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer
refers; and sign and date each sheet.
3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been
married and the question asks “Provide the name of your current spouse”), type or print “N/A,” unless otherwise
directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many
children do you have” or “How many times have you departed the United States”), type or print “None,” unless
otherwise directed.
4. Applicants for Initial Parole and those applicants seeking Re-parole should fill out most parts. See below for greater
detail.
5. You may file this form either from within the United States or outside the United States.
6. If you currently are an entrepreneur parolee and are requesting another period of entrepreneur parole, file this request
prior to the expiration of your current parole period but no earlier than 90 days before your current parole period
expires.

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Specific Instructions
Part 1., Item Number 6. USCIS Online Account Number (if any). If you have previously filed an application,
petition, or request using the USCIS online filing system (previously called USCIS Electronic Immigration System
(USCIS ELIS)), provide the USCIS Online Account Number you were issued by the system. You can find your USCIS
Online Account Number by logging in to your account and going to the profile page. If you previously filed certain
applications, petitions, or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online
Account Access Notice issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online
Account Number can be found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in
the space provided. The USCIS Online Account Number is not the same as an A-Number.

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Part 1., Item Number 16.a. Form I-94 Arrival-Departure Record. If U.S. Customs and Border Protection (CBP) or
USCIS issued you a Form I-94, Arrival-Departure Record, provide your Form I-94 number and date that your authorized
period of stay expires or expired (as shown on Form I-94). The Form I-94 number also is known as the Departure
Number on some versions of Form I-94.
NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, you may have
been issued an electronic Form I-94 by CBP, instead of a paper Form I-94. You may visit the CBP website at
www.cbp.gov/i94 to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this service. Some
travelers admitted to the United States at a land border, airport, or seaport, after April 30, 2013, with a passport or travel
document, who were issued a paper Form I-94 by CBP, may also be able to obtain a replacement Form I-94 from the CBP
website without charge. If your Form I-94 cannot be obtained from the CBP website, it may be obtained by filing Form
I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a
fee for this service.
Part 1., Item Numbers 16.b. - 16.f. Passport and Travel Document Numbers. If you used a passport or travel
document to travel to the United States, enter either the passport or travel document information in the appropriate space
on the application, even if the if the passport or travel document is currently expired.
Part 2. Biographic Information. Provide the biographic information requested in Part 2., Item Numbers 1. - 6. on the
application. Providing this information as part of your application may reduce the time you spend at your USCIS ASC
appointment as described in the Biometric Services Appointment section of these Instructions.
A. Ethnicity and Race. Select the boxes that best describe your ethnicity and race.
Categories and Definitions for Ethnicity and Race

(1) Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race. (NOTE: This category is only included under Ethnicity in Part 2., Item
Number 1.)
(2) White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
(3) Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.
(4) Black or African American. A person having origins in any of the black racial groups of Africa.
(5) American Indian or Alaska Native. A person having origins in any of the original peoples of North and
South America (including Central America), and who maintains tribal affiliation or community attachment.
(6) Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
Item Number 3. Height. Select the values that best match your height in feet and inches. For example, if you are five
feet and nine inches, select “5” for feet and “09” for inches. Do not enter your height in meters or centimeters.

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Item Number 4. Weight. Enter your weight in pounds. If you do not know your weight, or need to enter a weight under
30 pounds or over 699 pounds, enter “000.” Do not enter your weight in kilograms.
Item Number 5. Eye Color. Select the box that best describes the color of your eyes.
Item Number 6. Hair Color. Select the box that best describes the color of your hair.
Part 7. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
Item Numbers 1.a. - 6.b. Select the appropriate box to indicate whether you read this application yourself or whether
you had an interpreter assist you. If someone assisted you in completing the application, select the box indicating that you
used a preparer. Further, you must sign and date your application and provide your daytime telephone number, mobile
telephone number (if any), and email address (if any). Every application MUST contain the signature of the applicant (or
parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

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NOTE: As a condition of entrepreneur parole, you must maintain household income that is greater than 400 percent of
the Federal Poverty Guidelines as defined by the Department of Health and Human Services. Failure to comply with this,
or any other condition of parole, may result in a termination of your parole.
Part 8. Interpreter's Contact Information, Certification, and Signature

Item Numbers 1.a. - 7.b. If you used anyone as an interpreter to read the Instructions and questions on this application to
you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and
address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone
number (if any), and his or her email address (if any). The interpreter must sign and date the application.
Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than
the Applicant
Item Numbers 1.a. - 8.b. This section must contain the signature of the person who completed your application, if other
than you, the applicant. If the same individual acted as your interpreter and your preparer, that person should complete
both Part 8. and Part 9. If the person who completed this application is associated with a business or organization, that
person should complete the business or organization name and address information. Anyone who helped you complete
this application MUST sign and date the application. A stamped or typewritten name in place of a signature is not
acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he or she
may be obliged to also submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, or Form G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines
of the United States, along with your application.
Part 10. Additional Information
If you need extra space to provide any additional information within this application, use the space provided in Part 10.
Additional Information. If you need more space than what is provided in Part 10., you may make copies of Part 10. to
complete and file with your application, or attach a separate sheet of paper. Type or print your name and A-Number (if
any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers;
and sign and date each sheet.
We recommend that you print or save a copy of your completed application to review in the future and for your
records. If you are in the United States, we recommend that you review your copy of your completed application
before you come to your biometric services appointment at a USCIS ASC. At your appointment, USCIS will
permit you to complete the application process only if you are able to confirm, under penalty of perjury, that all of the
information in your application is complete, true, and correct. If you are not able to make that attestation in good faith
at that time, USCIS will require you to return for another appointment.

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Evidence for Initial Entrepreneur Parole
1. What documents should you submit with your Form I-941?
You do not need to submit original documents unless USCIS requests them.
A. Establishing that you are an Entrepreneur with a Qualifying Start-up Entity. Evidence and supporting documents
that you file with your Form I-941 should show that you:

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(1) Have a central and active role in the operations of a start-up entity, such that you are well-positioned, due to
your knowledge, skills, or experience, to substantially assist the U.S. start-up entity with the growth and
success of its business;
(2) Possess at least a 10% ownership stake in the U.S. start-up entity, and that the entity:

(a) Was recently formed (for example, created within the three years immediately preceding the filing date of
your Form I-941) and has been lawfully doing business within the United States during any period of
operation since its date of formation; and
(b) Has substantial potential for rapid growth and job creation, evidenced by the receipt of significant capital
investment, grants or awards.
B. Substantial Investment, Grant or Award. You may be considered for parole if you demonstrate that your start-up
entity has received a minimum investment amount or qualified award or grant as described below:
(1) The start-up entity has received a qualified investment, within 18 months immediately preceding the filing of
your Form I-941, of at least $264,147 from one or more qualified investors;
(2) The start-up entity has received, within 18 months immediately preceding the filing of your Form I-941, an
amount of $105,659 or more through one or more qualified government awards or grants; or
(3) If your start-up entity partially meets one or more of the above criteria, you may still be considered for
entrepreneur parole by providing other reliable and compelling evidence of the start-up entity's substantial
potential for rapid growth and job creation.
NOTE: If relying on other evidence that you believe is reliable and compelling, you will also need to show that
your entity has:
(1) Received a substantial level of investment (although less than $264,147), or

(2) Received a substantial level of government funding (although less than $105,659).
C. Investment must be from a Qualified Investor. The term “qualified investor” for purpose of entrepreneur parole
means an individual who is a U.S. citizen or lawful permanent resident of the United States, or an organization that
is located in the United States and operates through a legal entity organized under the laws of the United States or
any state, that is majority owned and controlled, directly and indirectly, by U.S. citizens or lawful permanent
residents of the United States, provided such individual or organization regularly makes substantial investments in
start-up entities that subsequently exhibit substantial growth in terms of revenue generation or job creation. Such
an individual or organization may be considered a qualified investor if, during the preceding five years:
(1) The individual or organization made investments in start-up entities in exchange for equity or convertible debt
or other security convertible into equity commonly used in financing transactions within their respective
industries comprising a total in such 5-year period of no less than $633,952; and
(2) Subsequent to such investment by such individual or organization, at least 2 such entities each created at least
5 qualified jobs or generated at least $528,293 in revenue with average annualized revenue growth of at least
20%.

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NOTE: An individual or organization that has been permanently or temporarily enjoined from participating in
the offer or sale of a security or in the provision of services as an investment adviser, broker, dealer, municipal
securities dealer, government securities broker, government securities dealer, bank, transfer agent or credit rating
agency, barred from association with any entity involved in the offer or sale of securities or provision of such
services, or otherwise found to have participated in the offer or sale of securities or provision of such services in
violation of law is not a qualified investor.
D. Additional Supporting Evidence. In addition to meeting the investment, grant or award criteria discussed above,
you should submit additional supporting evidence concerning the start-up entity's business and its substantial
potential for rapid growth and job creation as well as your day-to-day role in the business.

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If your start-up entity partially meets the qualified investment, government grant or award criteria, you may still
be considered for parole by providing other reliable and compelling evidence that the start-up entity has
substantial potential for rapid growth and job creation. Such supporting evidence may include, but is not limited
to the following:
(a) Evidence of rapid growth, such as: number of users or customers; revenue generated by the start-up entity;
additional investments/fundraising, including crowd funding platforms;
(b) Social impact of the start-up entity;

(c) National scope of the start-up entity's locality or region;

(d) Positive effects on the start-up entity's locality or region;

(e) Any other reliable and compelling evidence that the start-up entity has substantial potential for rapid
growth and job creation.
2. What documents do you need to provide to prove identity?
Submit copies of any of the following:
A. Passport;

B. Birth certificate accompanied by photo identification;

C. Any national identity document from your country of origin bearing your photo and/or fingerprint;

D. Any U.S. government immigration or other document bearing your name and photograph (for example, EADs,
visas, driver's licenses, non-driver cards).
3. What documents do you need to provide to show that you have a central and active role in the start-up entity?
You must provide a detailed description of your central and active role in the start-up entity along with supporting
evidence that may include, but is not limited to the following:
A. Letters from relevant government agencies, qualified investors, or established business associations with knowledge
of the entity's research, products or services and/or your knowledge, skills or experience that would advance the
entity's business;
B. Newspaper articles or other similar evidence that you or your entity has received significant attention or
recognition; Any national identity document from your country of origin bearing your photo and/or fingerprint;
C. Evidence that you or your entity has been recently invited to participate in, is currently participating in, or has
graduated from one or more established and reputable start-up accelerators;
D. Evidence that you have played an active and central role in the success of prior start-up entities;
E. Degrees or other documentation indicating that you have knowledge, skills, or experience that would significantly
advance the entity's business;

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F. Documentation pertaining to intellectual property of the start-up entity, such as a patent, that was obtained by you
or as a result of your efforts and expertise;
G. Position description of your role in the operations of the company; and
H. Any other reliable evidence indicating that you perform a central and active role in the start-up entity.
4. What documents do you need to provide to show your ownership stake in the start-up entity?
Submit copies of any relevant documents such as:

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A. Organizational documents (such as articles of incorporation, bylaws, articles of organization, operating
agreement, certificate of partnership, partnership agreement, etc.);
B. Equity purchase or grant agreements;
C. Equity ledger;

D. Equity certificates;

E. Ownership schedule; or
F. Capitalization table.

5. What documents do you need to provide to show that your company meets the definition of start-up entity?
Submit copies of any relevant documents such as:

A. Organizational documents (such as articles of incorporation, bylaws, articles of organization, operating
agreement, certificate of partnership, partnership agreement, etc.);
B. Tax records; or

C. Financial records; or

D. Other evidence establishing the company's potential for rapid growth and job creation.

6. What documents do you need to provide to show that the investment funds you have received came from a
qualified investor?
A. If the investor is an individual, you should submit a copy of a government-issued identity document showing the
photograph, name, and date of birth of the investor, along with evidence showing that the investor is a U.S.
citizen or lawful permanent resident of the United States. The copy must clearly show the photo and identity
information.
B. If the investor is an organization, such as a venture capital firm or other U.S. business investing in the start-up
entity, you should submit evidence that the organization operates through a legal entity organized under the laws
of the United States, such as its organizational documents (such as articles of incorporation, bylaws, articles of
organization, operating agreement, certificate of partnership, partnership agreement, etc.), along with evidence
showing that it is majority owned and controlled, directly and indirectly, by U.S. citizens or lawful permanent
residents of the United States, such as an ownership structure chart outlining the direct and indirect ownership of
the organization together with evidence that the individuals ultimately owning and controlling a majority of the
organization are U.S. citizens or lawful permanent residents of the United States.
C. Evidence that the investor has, during the 5 years prior to the date of filing your application for parole based on an
investment from such individual or organization:
(1) Made investments in other U.S. business entities in exchange for equity or convertible debt or other security
convertible into equity commonly used in financing transactions within their respective industries comprising
a total in such 5-year period of no less than $633,952; and
(2) Subsequent to such investment by such individual or organization, at least 2 such entities each created at least
5 qualified jobs or generated at least $528,293 in revenue with average annualized revenue growth of at least
20%.
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To satisfy the investment requirement, such evidence may include such records as: bank records, wire transfers,
debt agreements, equity purchase agreements, equity certificates, equity ledgers, or capitalization table. To satisfy
the job creation or revenue generation requirement, such evidence may include such records as: tax and/or payroll
records, I-9 records, or audited financial statements.
7. What documents do you need to provide to show that the award or grant you have received is a qualified government
award or grant?
To establish that the award or grant is for economic development, research and development, or job creation (or other
similar monetary award typically given to start-up entities) made by a federal, state, or local government entity that
regularly provides such awards or grants to start-up entities, you should submit such records as: copies of grant or
award letters, other documentation from the government entity confirming the issuance of the award or grant including
the amount of the award or grant as well as the recipient, and bank records confirming receipt of the award or grant.

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8. What documents do you need to provide to show that your start-up entity received sufficient minimum investment or
government funding?
Evidence that the start-up entity has received sufficient minimum investment to establish eligibility may include
copies of the start-up entity's bank records, accounting documents, and corporate ownership records. These records
must clearly demonstrate the trail of lawfully derived capital from a qualified investor into your start-up entity. The
records must demonstrate that the invested capital was used to purchase equity, convertible debt, or other security
convertible into equity issued by your start-up entity. Evidence may also include documents showing receipt by the
start-up entity of a qualified award or grant from a U.S. government entity.
NOTE: A qualified investment shall not include an investment from you (the entrepreneur), your parents, spouse,
brother, sister, son, or daughter; or from any corporation, limited liability company, partnership, or other entity in
which you or your parents, spouse, brother, sister, son, or daughter directly or indirectly has any ownership stake.
9. What documents do you need to provide to show that the investment in your start-up entity came from a lawful
source?
Evidence that the funds invested into the start-up entity came from a lawful source to establish eligibility may include
such records as: copies of the investor's bank records, tax records, employment history, wage records, or evidence of
assets or property. These records must clearly demonstrate the trail of lawfully derived capital from a qualified
investor into your start-up entity.
10. What additional documents could you provide to show that you will provide a significant public benefit to the
United States?
In addition to meeting the investment, grant or award criteria discussed above, you should submit additional
supporting evidence concerning your start-up entity's business and its substantial potential for rapid growth and job
creation (as well as your day-to-day role in the business). Such supporting evidence may include, but is not limited to
the following:
A. Evidence of investments from qualified investors, government awards or grants, or revenue generation, such as
bank records, wire transfers, equity purchase agreements, equity certificates, equity ledgers, or capitalization
table;
B. Letters from relevant government agencies, qualified investors, or established business associations with
knowledge of the entity's research, products or services and/or your knowledge, skills or experience that would
advance your entity's business;
C. Newspaper articles or other similar evidence that you or your entity has received significant attention or
recognition;
D. Evidence that you or your entity have been recently invited to participate in, are currently participating in, or have
graduated from one or more established and reputable start-up accelerators;

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E. Patent awards or other documents indicating that you and/or your entity are focused on developing new
technologies or cutting-edge research;
F. Evidence that you have played an active and central role in the success of prior start-up entities, such as letters
from relevant government agencies, qualified investors, or established business associations with knowledge of
your prior start-up entities;
G. Degrees or other documentation indicating that you have knowledge, skills, or experience that would significantly
advance your entity's business;

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H. Tax and/or payroll records, I-9 records, or other documents indicating that your entity has created a significant
number of qualified jobs prior to filing the request for parole; and
I. Any other reliable evidence indicating your entity's potential for growth and/or your ability to advance your
entity's business in the United States.
NOTE: If this list of evidence does not apply to your entrepreneurial activities, you may submit any other evidence
that a grant of parole will provide a significant public benefit to the United States based on your role as an
entrepreneur of a start-up entity.
11. What additional documents do you need to provide for your spouse and dependent children?

Requests for parole for the spouse and children of an entrepreneur must be filed with Form I-131. Evidence establishing
your family relationship such as a marriage certificate and birth certificate should be submitted with Form I-131.

Evidence for Requests for Re-Parole

What documents do you need to provide when requesting an additional period of parole?
1. Evidence that you continue to meet the definition of “entrepreneur”:
A. You have a central and active role with the start-up entity; and
B. You possess at least a 5% ownership stake.

2. Evidence that your entity continues to meet the definition of a “start-up entity”.
3. Evidence that your qualifying U.S. start-up entity has:

A. Received at least $528,293 in qualifying investments, qualified government grants or awards, or a combination of
such funding, during the initial parole period;
B. Created at least 5 qualified jobs with the start-up entity during the initial parole period; or
C. Reached at least $528,293 in annual revenue in the United States and averaged 20% in annual revenue growth
during the initial parole period.
If your start-up entity partially meets funding, job creation, or annual revenue criteria, you may still be considered for
re-parole by providing other reliable and compelling evidence that the start-up entity continues to show substantial
potential for rapid growth and job creation.
4. Evidence that the start-up entity has received sufficient minimum investment to establish eligibility may include
copies of the start-up entity's bank records, accounting documents, and corporate ownership records. These records
must clearly demonstrate the trail of lawfully derived capital from a qualified investor into your start-up entity. The
records must demonstrate that the invested capital was used to purchase equity, convertible debt, or other security
convertible into equity issued by your start-up entity. Evidence may also include a record demonstrating a qualified
grant or award from a U.S. Government entity to the start-up entity; or a combination of qualified investor or
government entity funding.

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NOTE: A qualified investment shall not include an investment from you (the entrepreneur), your parents, spouse,
brother, sister, son, or daughter; or from any corporation, limited liability company, partnership, or other entity in
which you or your parents, spouse, brother, sister, son, or daughter directly or indirectly has any ownership stake.
5. Evidence that the start-up entity has generated sufficient revenue to establish eligibility may include such records as:
copies of relevant company accounting; tax and bank records, such as copies of the company's most recent U.S.
federal tax returns, including all schedules and attachments; or audited financial statements.
6. Evidence that the start-up entity has created the required number of qualified jobs may include tax and/or payroll
records, I-9 records, or other documentation showing job creation.

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7. Additional Supporting Evidence. In addition to meeting the investment, grant or award, or revenue criteria
discussed above, you should submit additional supporting evidence concerning the start-up entity's business and its
substantial potential for rapid growth and job creation (as well as your day-to-day role in the business).

Reporting a Material Change

If you are granted entrepreneur parole, you may submit this form with the fee as an amended application to report any
material change. Failure to timely file this form with the fee to report a material change may result in termination of your
parole.
NOTE: Material change means any change in facts that could reasonably affect the outcome of the determination that
you provide, or continue to provide, a significant public benefit to the United States. A material change may include, but
is not limited to the following:
1. Any criminal charge, conviction, plea of no contest, or other judicial determination in a criminal case concerning the
entrepreneur or start-up entity;
2. Any complaint, settlement, judgment, or other judicial or administrative determination concerning the entrepreneur or
start-up entity in a legal or administrative proceeding brought by a government entity;
3. Any settlement, judgment, or other legal determination concerning the entrepreneur or start-up entity in a legal
proceeding brought by a private individual or organization other than proceedings primarily involving claims for
damages not exceeding 10% of the current assets of the entrepreneur or start-up entity;
4. A sale or other disposition of all or substantially all of the start-up entity's assets;
5. The liquidation, dissolution, or cessation of operations of the start-up entity;
6. The voluntary or involuntary filing of a bankruptcy petition by or against the start-up entity;
7. A significant change with respect to ownership and control of your start-up entity; and
8. A cessation of your qualifying ownership interest in the start-up entity or your central and active role in the operations
of that entity.

What Is the Filing Fee?
The filing fee for Form I-941 is $1,200.
A biometric services fee of $85 is required for the entrepreneur.
NOTE: The filing fee and biometric services fee are not refundable, regardless of any action USCIS takes on this
application. DO NOT MAIL CASH. You must submit all fees in the exact amounts.
Use the following guidelines when you prepare your checks or money orders for the Form I-941 filing fee and
biometric services fee:
1. The check or money order must be drawn on a bank or other financial institution located in the United States and must
be payable in U.S. currency; and
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2. Make the checks or moneys order payable to U.S. Department of Homeland Security.
NOTE: Spell out U.S. Department of Homeland Security; do not use the initials “USDHS” or “DHS.”
3. If you live outside the United States, contact the nearest U.S. Embassy or U.S. Consulate for instructions on the
method of payment.
Notice to Those Making Payment by Check. If you send us a check, USCIS will convert it into an electronic funds
transfer (EFT). This means we will copy your check and use the account information on it to electronically debit your
account for the amount of the check. The debit from your account will usually take 24 hours and your bank will show it
on your regular account statement.

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You will not receive your original check back. We will destroy your original check, but will keep a copy of it. If USCIS
cannot process the EFT for technical reasons, you authorize us to process the copy in place of your original check. If
USCIS cannot complete the EFT because of insufficient funds, we may try to make the transfer two additional times.
How To Check If the Fees Are Correct

Form I-941's filing fee and biometric services fee are current as of the edition date in the lower left corner of this page.
However, because USCIS fees change periodically, you can verify that the fees are correct by following one of the steps
below.
1. Visit the USCIS website at www.uscis.gov, select “FORMS,” and check the appropriate fee; or

2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for fee information. For TTY (deaf or
hard of hearing) call: 1-800-767-1833.
NOTE: If your Form I-941 requires payment of a biometric services fee for USCIS to take your fingerprints, photograph,
and/or signature, you can use the same procedure to obtain the correct biometric services fee.

Where to File?

Please see our website at www.uscis.gov/I-941 or call our National Customer Service Center at 1-800-375-5283 for the
most current information about where to file this application. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Address Change

An applicant who is not a U.S. citizen must notify USCIS of his or her new address within 10 days of moving from his or
her previous residence. For information on filing a change of address, go to the USCIS website at www.uscis.gov/
addresschange or contact the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of
hearing) call: 1-800-767-1833.
NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not
process change of address requests.

Processing Information
DHS will reject any Form I-941 that is not signed or accompanied by the correct filing fees. You may correct the deficiency
and resubmit Form I-941. Form I-941 is not considered properly filed until accepted by a USCIS Lockbox Facility.
Initial Processing. Once USCIS accepts your application we will check it for completeness. If you do not completely fill
out this application, you will not establish a basis for your eligibility and USCIS may reject or deny your application.
Requests for More Information. We may request that you provide more information or evidence to support your
application. We may also request that you provide the originals of any copies you submit. If USCIS requests an original
document from you, it will be returned to you after USCIS determines it no longer needs your original.

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NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be
immediately destroyed upon receipt.
Requests for Interview. We may request that you appear at a USCIS office for an interview based on your application.
At the time of any interview or other appearance at a USCIS office, we may require that you provide your fingerprints,
photograph, and/or signature to verify your identity and/or update background and security checks.
Decision. The decision on Form I-941 involves a determination of whether you have established eligibility for the
immigration benefit you are seeking. USCIS will notify you of the decision in writing.

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NOTE: The final decision to grant parole into the United States to someone outside of the United States will be made by
CBP at the time you appear at a Port -of- Entry.

USCIS Forms and Information

To ensure you are using the latest version of this application, visit the USCIS website at http://www.uscis.gov where you
can obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may
order USCIS forms by calling the USCIS Contact Center at 1-800-375-5283. The USCIS Contact Center provides
information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at
http://www.uscis.gov. Select “Tools,” the under “Self Service Tools,” select “Appointments” and follow the screen
prompts to set up your appointment. Once you finish scheduling an appointment, the system will generate an appointment
notice for you.

Penalties

If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-941, we will
deny your Form I-941 and may deny any other immigration benefit. In addition, you will face severe penalties provided
by law and may be subject to criminal prosecution.

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this application, and the associated evidence, is collected under the
Immigration and Nationality Act (INA) sections 103(a)(1) and (3), 8 U.S.C. 1103(a)(1), (3); INA 274A(h)(3)(B), 8 U.S.C.
1324a(h)(3)(B); INA 212(d)(5), 8 U.S.C. 1182(d)(5); and sections 101(b)(1)(F) and 402(4) of the Homeland Security Act.
PURPOSE: DHS uses the information you provide on this application to determine whether you meet the criteria for
consideration for significant public benefit parole as an entrepreneur and otherwise merit a favorable exercise of DHS'
parole authority.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information,
including your Social Security number (if applicable), and any requested evidence, may delay a final decision or result in
denial of your application.
ROUTINE USES: DHS may share the information you provide on this application and any additional requested
evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows
approved routine uses described in the associated published system of records notices [DHS/USCIS-001 - Alien File,
Index, and National File Tracking System and DHS/USCIS-007 - Benefits Information System] and the published privacy
impact assessments [DHS/USCIS/PIA-016a Computer Linked Application Information Management System 3 and
Associated Systems] which you can find at www.dhs.gov/privacy. DHS may also share this information, as appropriate,
for law enforcement purposes or in the interest of national security.

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Paperwork Reduction Act
An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of
information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public
reporting burden for this collection of information is estimated at 4 hours and 42 minutes per response, including the time
for reviewing instructions, gathering the required documentation and information, completing the application, attaching
necessary documentation, and submitting the application. The collection of biometrics is estimated to require 1 hour and
10 minutes. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Office of Policy and Strategy,
Regulatory Coordination Division, 5900 Capitol Gateway Drive, Mail Stop #2140, Camp Springs, MD 20588-0009;
OMB No. 1615-0136. Do not mail your completed Form I-941 to this address.

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